Provider Demographics
NPI:1740387604
Name:PHUNG, ANDREW (DDS)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:
Last Name:PHUNG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2160 SUNSET BLVD
Mailing Address - Street 2:SUITE 503
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95765
Mailing Address - Country:US
Mailing Address - Phone:916-771-0757
Mailing Address - Fax:
Practice Address - Street 1:2160 SUNSET BLVD
Practice Address - Street 2:SUITE 503
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95765
Practice Address - Country:US
Practice Address - Phone:916-771-0757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA515121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice